A Program of the Central Pennsylvania Animal Alliance
	Application to Adopt Bailey Pet's Name:  Name  What kind of pet are you interested in:  * Required     Choose an answer: Dog Cat Bird Reptile Small mammal Other If you are interested in a STAR pet, what attracted you to this pet:     Which animal are you interested in:     Choose an Animal: Blackie Chase Dunkin Oreos Gigi Jinx Little Miss Sandy Loki Mora Our Little Girlfriend Plato & Socrates Reggie Why are you interested in adopting a pet at this time:  * Required     Will the animal be kept inside or outside:  * Required     Choose an answer: Inside Only Outside Only Inside and Outside How much time will the animal spend alone during the day:  * Required     Where will the animal be kept when you are not home during the day? Also include where the pet will stay when you go on vacation:  * Required     Where will the animal be kept when you are home:  * Required     Where will the animal sleep:  * Required     What type of exercise, socialization, or other interaction will this pet receive and how often:  * Required       In what type of home do you live:  * Required     Choose an answer: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing Do you own or rent your home:  * Required     Choose an answer: Rent Own If you rent, please enter your landlord's name and phone number:  * Required     How many people reside in your household? Please list their ages, any allergies to pets, and their occupation:  * Required     Who in the household will care for the pet:  * Required     Is your yard fenced:  * Required     Choose an answer: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced What is the height of the fence:  * Required     What type of fence:  * Required     Choose an answer: Privacy Chain Link Invisible What sized yard do you have:     Have you ever given up a pet? If yes, please explain:  * Required     Have you applied with any other rescue:  * Required     Choose an answer: Yes No List at least two references (who are not family members), their phone number and time when they can be reached:  * Required     Veterinarian's Name and Phone Number:  * Required     Under what circumstances would you rehome a pet:  * Required       Do you currently have any pets:  * Required     Choose an answer: Yes No Have you had pets in the past:  * Required     Choose an answer: Yes No This and the following questions are to provide us with your animal history. Email us if you have more than 5 pets (including animals from your adult life that are no longer with you)Animal 1 (Please Check each box that is applicable for this pet:    Dog  Cat  Other species  Female  Male  Spayed/neutered  Up-to-date on shots  Annual vet exams  Currently own  Passed away  Gave away Animal 2:    Dog  Cat  Other species  Female  Male  Spayed/neutered  Up-to-date on shots  Annual vet exams  Currently own  Passed away  Gave away Animal 3:    Dog  Cat  Other species  Female  Male  Spayed/neutered  Up-to-date on shots  Annual vet exams  Currently own  Passed away  Gave away Animal 4:    Dog  Cat  Other species  Female  Male  Spayed/neutered  Up-to-date on shots  Annual vet exams  Currently own  Passed away  Gave away Animal 5:    Dog  Cat  Other species  Female  Male  Spayed/neutered  Up-to-date on shots  Annual vet exams  Currently own  Passed away  Gave away I certify that the information entered on this applicant is true. Enter your name and date:  * Required
	Hounds of Prison Education A Program of the Central Pennsylvania Animal Alliance